Baby and the Bathwater

Photo credit: Tatiana Vdb

Photo credit: Tatiana Vdb

Adam Meakins (please follow him on Twitter) wrote a recent post about therapists getting a little too focused on the psychosocial components of pain forgetting that there can be and often is a biological component as well. Although it is not necessary to read it in order to follow this post, it is a short, well stated read. Once he posted it, I saw two things happen that I found disappointing:

1. The strawman implying that Adam was saying we need to ignore the psychosocial aspect of pain.

2. People interpreting what he wrote as supporting their own absolute belief in structuralism and therefore condoning their own weird crazy approach.

Both are bullshit and make me want to bang my head against the wall in frustration. The purpose of this post is to try to clarify things a bit. Here is a bulleted list of the take home points on this concept.

There is a neuropsychosocial component to ALL pain

All of my patients from non-specific pain to postsurgical recovery get this education. My oversimplified explanation to the patient is that the body has experienced some significant pain and it is perfectly reasonable to expect that the nervous system would become fearful that something is horribly wrong down there. This makes it hyper-aware of ANY sensation coming from that area asking, “What was that?!?!? Am I being hurt again down there?!?!?” The term I use is “gun-shy” since, in my mind, it really seems like a region-specific and isolated version of post-traumatic stress disorder (PTSD).

It has every right to feel this way and should be considered normal in the short term. We just don’t want it to run out of control. Then I discuss positive feedback loops. I know that this is oversimplified but I find that the patient grasps it quickly, happily, and, most importantly, calmly. They also quickly understand how depression and other life-stresses can easily amplify this.

This idea is not new

I graduated in 1998 – 16 years ago. My final thesis was on the psychosocial component of pain. I sure as hell didn’t come up with it. I wrote an unpublished paper with a ton of psychology citations that had long before identified and explored this concept. I came up with the idea to review that topic for my final because I had been working as an aide in a clinic that was using education, operant conditioning, and graded exposure to treat chronic pain. Sure, we now have a better understanding of the mechanisms of this phenomenon with central-sensitization and whatnot, but it is still the same idea. Keep in mind, there are inherent issues with chronic pain that even if you do everything right, the success rate is low. That is especially true if there is zero biological component to their pain. Education is huge.

Biological components are your first concern and your primary role as a medical provider is to rule them out

Shit. I had to say that didn’t I? Before you freak out at how archaic, simplistic, and “meat-oriented” I am being let’s look at this from a patient centered approach. If you were a patient (you will be someday – trust me) why would you seek medical evaluation in the first place? What is the first question you are asking? Is it:

1. “Would you please address my psychosocial issues that are interwoven with my pain?” or

2. “Would you please tell me if something is injured and can be fixed?”

Your first job is to rule out known biological factors that can and should be addressed. Not in isolation of course. (I just wrote two paragraphs above describing how I address neuropsychosocial issues in ALL patients you strawman building bastard!!!) This is the crux of what Adam was getting at. I have seen way too many patients with clear signs of an easily corrected hip injury who have been told that there is nothing wrong with their hip and they just have chronic pain – learn to deal with it. Once they get properly diagnosed and treated sustaining huge relief and return of function, there is only one word to describe their feelings towards their previous provider:


Sometimes we misinterpret truths like “Disk herniations do not ALWAYS cause pain” into completely false statements like “Disk herniations NEVER cause pain.” Those are two completely different statements that do not automatically go together. It is your responsibility as a medical provider to do your due diligence so when you say, “There is nothing wrong with the tissue”, you can be damn sure of it. This is why you should always perform a proper differential diagnosis.

Once known biological components have been ruled out – DROP IT

I said “first concern”, not “only concern”. (You strawman building bastards!!!) This is a HUGE issue in the physical therapy profession. Once you have effectively ruled out biological diagnoses, move on. As I tell the patient, “I see no obvious signs of anything significant that would require further workup at this time,” and then review the current plan. Maybe explore the possibility of a positive feedback loop and address that. Remember, rule OUT, not rule IN. Why? Because confirmation bias is a bitch. Science falsifies; it doesn’t confirm. One of my biggest pet peeves is when therapists make up bullshit biological and structural explanations that cannot be falsified and then focus all of their “treatments” there.

Trust me. Adam was referring to KNOWN biological issues, not the crap you made up.

This is the problem that the psychosocial folks rightfully have with a lot of medical practice. The misunderstanding that ALL pain MUST HAVE a purely biological component. It is perfectly okay to come back to your differential from time-to-time, especially as new possible biological components are identified and validated in the literature. Hey, we all make mistakes. But don’t perseverate on some made up diagnosis that just confuses (or worse, frightens) the patient.

Don’t throw the baby out with the bathwater

So quit with the false dichotomy (100% this or 100% that) nonsense. Also quit with the “all approaches are valid” nonsense. Just follow the science and stay off the pendulum of popular ideas. Or in other words:

Whenever you find yourself on the side of the majority, it is time to pause and reflect.
-Mark Twain

Like nocioception, just because psychosocial components are a thing, that doesn’t mean they are always the ONLY thing.